Creation of a Neonatal Thrombosis Center and its Use to Successfully Treat Infants with Severe Thromboses

Abstract

Background: Clinically significant thrombosis, which can be life threatening, is a common problem in the neonatal period, affecting up to 6.8 per 1,000 neonatal intensive care admissions. These infants have increased risk for bleeding complications from anticoagulant therapy due to immature coagulation systems, concomitant infections, inflammation and coagulopathies, and CNS hemorrhage risk due to prematurity. Thus, care for these infants requires a specialized multidisciplinary team, composed of neonatologists and hematologists, along with pharmacy support. Objectives: We aim to describe the development of a neonatal thrombosis center at our institution, co-run by a neonatologist with expertise in neonatal hematology, and a pediatric hematologist. The utility of the center will be explored through the case review of four neonates with large, life threatening thromboses, successfully treated with systemic tissue plasminogen activator (TPA). We will also describe the development of a neonatal thrombosis database for studying risk factors and treatments for neonatal thrombosis. Methods: Protocols for evaluation and treatment of neonatal thromboses were prepared, based on literature review and best practices, and presented and approved by the institution’s pharmacy and therapeutics committee. Anticoagulation protocols including heparin, low molecular weight heparin, and systemic TPA were created electronically within our computerized order entry system. A protocol for consulting the neonatal thrombosis team was created and presented during grand rounds. All neonates with thromboses are followed by the neonatal thrombosis team as outpatients, with thrombophilia evaluations completed as necessary. Information regarding age, risk factors, diagnoses, treatments and outcomes are then compiled in a neonatal thrombosis database. Results: Four infants with life-threatening thromboses were successfully treated with systemic TPA using our neonatal thrombosis treatment center. These include a full-term infant with an occlusive thrombus in the main pulmonary artery, a full term infant with a mural thrombus in the heart, a full term infant with an occlusive thrombus in the aortic arch, and a 26-week premature infant with a large right atrial thrombus. Conclusion: Neonates, especially those in intensive care, are at increased risk for thromboses, which can be life-threatening. Treatment of neonates with significant thromboses requires a multidisciplinary approach. Creation of a neonatal-thrombosis team and treatment center can be used to effectively treat these patients and gather data about their care and outcomes. To our knowledge, this is one of the first dedicated neonatal thrombosis teams.